Understanding and Treating Male Survivors of Childhood Sexual Abuse
The Invisibility of Male CSA
It is largely unknown to most that around one-in-six males (16%) have experienced childhood sexual abuse (CSA) before the age of 18, yet rates of disclosure are significantly lower than for female survivors (1in6, 2017). The way male socialization emphasizes being strong, in control, and invulnerable plays a significant role in the challenges around acceptance and disclosure. When they do share about their abuse, it is common to be met with skepticism, minimization, or questions or doubts about their sexuality. One popular myth that amplifies the stigma for male survivors is that most eventually go on to perpetrate, yet the overwhelming majority do not (Leach et al., 2016). Further, sexual abuse is not defined only by age, its key characteristics include coercion, manipulation, and a power imbalance.
Sexual abuse in boys frequently becomes an injury to identity and the developing self (Gartner, 2001; Herman, 1992). The violation becomes intertwined with the developmental process of growing into adulthood and the expectations of what it means to be male. Generally, survivors are often left with the question, “What happened?” and “How could this happen?” Male survivors are often also left with, “What does this say about me as a man?”
In clinical contexts, a male survivor rarely immediately discloses that he was sexually abused. Instead, he often presents with shame, detachment, numbness, passivity, difficulties with vulnerability and intimacy, sexual confusion, and/or performative masculinity. Therapists unaware of these possible dynamics might underestimate the role of shame. They may also misinterpret or not know how to deal with sexualized transference, or be quite confused by their own countertransference reactions. A psychodynamically informed framework is useful in understanding how masculinity’s norms intersect with CSA and how shame becomes a central affect driving intra-and-interpersonal dynamics, including with the therapist.
How Masculine Socialization Leads to Identity Fracture in the Aftermath of Abuse
At an early age, boys are socialized to equate manhood with strength, autonomy, invulnerability, and the ability to defend oneself whenever necessary. These norms shape how a boy metabolizes his experience(s) of sexual abuse, as the abuse contradicts those identity-based developmental expectations (Gartner, 2001). As such, one key aspect of the traumatic violation often includes identity fracture.
A male survivor often internalizes the belief that he should have stopped the abuse. This internalization may come to consciousness at a young age or in adulthood once he has fully recognized that he has been abused. Regardless, the internalization often resembles a narcissistic injury that communicates, “I failed at being a man.” He believes he “should have stopped it.” He may see himself as complicit in the abuse, or even wholly responsible for it, instead of finding fault in the perpetrator. In response, the survivor may find himself identifying strongly with traditional expressions of masculinity, including sexual conquest, emotional neutrality, or dominance. Alternatively, he might minimize himself or present passively in relationships, unconsciously recreating his powerlessness during the abuse. In both cases, he is seeking to avoid shame and humiliation.
The internalization of failed manhood can become exaggerated by multiple factors, including whether the survivor experienced physiological arousal or emotional excitement during the abuse. While it is generally known that females often experience physiological arousal during sexual trauma, it is rarely acknowledged in the context of male survivors. Socialization dictates that male arousal can only exist when desire and consent are present, and erections are seen by many to reflect agency, intention, and control. Physiological arousal during abuse, a common response for the male survivor (McLean et al., 2004), often becomes a profound source of confusion and shame. He may ask, “If my body responded, how can I say I was abused?” He does not perceive his own body as an ally of his desire; he sees it as having betrayed him.
The male survivor may also struggle with questions around his sexual identity. Despite there being zero evidence that CSA determines sexual orientation, he may present with obsessive doubts about what his abuse means about his sexual orientation. The obsessive nature of these questions often reflect a desire for certainty and agency in the wake of violation. In order to create a narrative that is palatable, he may also reframe the abuse as “just experimenting,” particularly when the abuser was closer in age.
Shame as the Central Organizing Affect
For the male survivor of CSA, shame often becomes the central organizing affect around which identity, sexuality, and/or relationships are structured (Herman, 1992; Nathanson, 1992). Though guilt says, “I did something bad,” shame says, “I am bad” (Nathanson, 1992), and the impacts of male socialization often serve as a shame-amplifier (Gartner, 2001).
A. Secrecy and Failed Protection
The male survivor commonly keeps his abuse a secret for two reasons: first, to protect himself from the internalized beliefs he has about himself, and second, to protect himself from anticipated humiliation were he to disclose. This secrecy tends to be self-protective but comes at a cost, as shame dwells and grows in secrecy (Herman, 1992). The longer he keeps the abuse a secret, the worse it must be in his eyes. As a result, the shame continually compounds on itself.
His shame can also be compounded by failures of protection. When caregivers are neglectful or inattentive, or they dismiss the child’s disclosure (explicitly or implicitly), the injury becomes two-fold. He is no longer only dealing with a sense of internal failure, he may come to believe he is unworthy of care and protection. Further, if the perpetrator is in the role of caregiver, the child is often most vulnerable to severe disruptions in identity and development, as there exist few avenues for which the boy can develop a sense of self-worth.
B. Shame as it Presents Clinically
There are several ways in which shame can manifest clinically. The male survivor may present as collapsed and depressed. He may seem withdrawn, struggle with motivation, and be highly self-critical. He may keenly experience the hatred he has for himself, and he may believe he deserves it. At extreme levels he may experience suicidality and self-harm. Relationally, he describes interpersonal dynamics that involve a frequent need for reassurance, irritability, and difficulty expressing himself for fear of judgment.
In some cases, the withdrawal can be less depressive and more dissociated. Though some may meet the criteria for dissociative disorders, more commonly the survivor experiences detachment, emotional numbing, difficulty identifying his internal experience (i.e., thoughts, emotions, sensations), and gaps in thought and memory. The survivor in such cases is unconsciously protecting himself from his shame by not fully embodying himself. Interpersonally, he may have difficulties around vulnerability, communication, and intimacy/closeness, which may be perceived by others as withholding.
Shame can also present as grandiose, likely a compensatory performance of masculinity. This involves frequent devaluation of others and interpersonal dominance. He may struggle to maintain and form relationships due to his emphasis on dominance and strength, which prevent stable collaboration and partnership. He is prone to perceiving the world hierarchically as a way to elevate himself above others in order to avoid his shame.
Relational Sequelae, Sexual Functioning, and Barriers to Disclosure
The male survivor’s attachment system is often scanning for and trying to avoid humiliation, rejection, or over-exposure. This can lead to various relational permutations, impacts on sexual functioning and dynamics, and barriers to disclosure.
A. Intimacy Avoidance
The male survivor may find himself avoiding intimacy in overt or subtle ways. In extreme cases, he might avoid all forms of sexual and emotional connection, resigning himself to isolation. More commonly, however, he withholds, either by conscious choice or unconsciously, some form of vulnerability. This might include an aversiveness to expressing his internal experience verbally or somatically (i.e., crying). His partner may be longing for deeper intimacy and closeness, leading to relational strain. He might maintain sexual relationships without emotional exposure or, alternatively, pursue emotional relationships that rarely involve physical touch or sexual intimacy. Ultimately, he is deeply afraid of being fully seen because he fears he will be discovered as defective and unworthy of love.
B. Compulsive Intimacy
He may also go in the opposite direction, developing instantaneous attachment and/or sexual intensity. In relationships, he may experience premature certainty. As the relationship progresses, he begins to need frequent reassurance due to his fear of abandonment. He may seek that reassurance by “testing” his partner’s love for and commitment to him. To the extent these relationships end, he struggles to be alone and will often shortly thereafter enter into a new relationship. In terms of sexual intensity, he may feel a compulsive need to have sex very often or otherwise feel deep anxiety, possibly at the expense of emotional intimacy. The internal narrative often involves securing someone as quickly as possible before they discover his “true nature” as defective.
C. Sexual Functioning and Dynamics
Sexual encounters often become an arena in which the survivor tries to resolve his trauma. For some, this can lead to erectile dysfunction due to “performance anxiety.” Unconsciously, this may be the body’s attempt to say “no” when he was unable to in the past. The abuse can lead him to have a hostile or ambivalent relationship to his body, making it difficult to experience or enjoy sexual stimulation by himself or others. He may also lose sexual desire once a relationship becomes emotionally intimate, protecting himself from sexual humiliation by someone he has begun to care deeply for.
In some cases, his capacity for arousal may be symbolically linked to his abuse. He may experience, or only be able to experience, arousal within the context of humiliation, submission, or domination. This usually exists within consensual adult relationships, though unresolved shame can distort boundaries for some.
D. Barriers to Disclosure
The male survivor often struggles greatly to disclose his abuse to others, including the therapist. He may fear being emasculated by others or perceived as weak, and he may minimize his abuse or expect others to. In cases where he has created an internal narrative that his abuse “wasn’t that bad,” there exists a strong defensive structure fighting against acceptance and disclosure. In some cases, his difficulty disclosing might be out of loyalty to his caregiver(s) and/or the perpetrator. The perpetrator may have a close relationship to the patient’s caregiver(s) and he is afraid of causing conflict. Loyalty to the perpetrator is more common when the perpetrator is a family member and/or if, outside of the abuse, the perpetrator expressed warmth toward him. More often, a disclosure occurs during a crisis, as disclosure is more than sharing information, it risks identity collapse.
The Treatment Relationship: Transference, Countertransference, and Working Through
The attachment expectations that exist as a result of the male survivor’s abuse inevitably come forward in the therapy relationship, which often becomes the first relational system capable of containing his internal working models. The below dynamics, which are protective and adaptive in nature, are consistent with relational psychoanalytic understandings of transference and countertransference in sexual abuse treatment (Davies & Frawley-O’dea, 1994).
Clinical Vignette
I met with a gay male patient who casually described a sexual relationship with his uncle. He spoke of it as if it was something mundane and with little to no affect. When I asked how he felt sharing it, he said, “I enjoyed it, so it’s not like it was abuse.” This is an example of protective minimization, as well as a possible unconscious test to see whether I would collude with him. He was simultaneously avoiding humiliation while wanting to be fully seen.
At the close of the session, he asked, “Do you think you can help me?” I expressed a sense of hopefulness. In the following session, he stated, “I don’t think talking can help me. I already know everything about myself.” He was expressing a level of certainty and self-confidence, yet underneath it was clear that there was a deep belief that I did not and could not care about him. He later said, “It doesn’t matter what you say, it’ll go right over my head.”
As treatment progressed, he oscillated between helplessness and hostility. When he perceived my misattunement or withdrawal, he lashed out. He seemed to find confirmation of my indifference as much as possible. I initially responded with reassurance, attempting to demonstrate care. I found myself talking more than usual and over-interpreting. Eventually, I realized that my frustration, helplessness, and urgency were countertransference responses. I became involved in an enactment of trying to rescue him.
A. Therapist as Judge or Unseeing Parent
In this transference/countertransference matrix, the patient may perceive the therapist as judging him or neglectful. He anticipates humiliation or emotional absence. The patient experiences himself as the potential or actual victim to the therapist as perpetrator. As a result, he watches the therapist closely for any sign of disapproval and/or he preemptively devalues the therapist. He may also minimize his abuse in order to avoid the possibility of judgment or non-reaction.
The therapist often feels ineffective, bored, devalued, or shut out and may lash out with frustration or anger, become hypervigilant over being critical, or become withdrawn. The frustration and anger generally comes from a place of helplessness, being devalued/accused, or needing to constantly provide reassurance. Hypervigilance over being critical and withdrawal are generally attempts at protecting the patient and the therapist from humiliation.
B. Therapist as Rescuer
Here, the patient expects the therapist to act as a rescuer. He unconsciously generates a protective response from the therapist, creating a strong impulse to rescue him from his suffering. The patient might present himself as fragile, wounded, broken, and incompetent, frequently expressing helplessness and appearing collapsed and devoid of purpose or self-worth. He, consciously or unconsciously, believes that the therapist is the only person who can save him from his suffering.
Countertransferentially, the therapist may over-interpret, experience high levels of emotional intensity early on, or soften boundaries. They may also collude with his helplessness by believing they cannot help or, alternatively, having a grandiose belief that they are the only one who can “fix” him. A therapist’s identity as a helper and healer makes them more likely to engage in these ways. Ultimately, as the rescue attempts repeatedly fail, the therapist may experience frustration or withdrawal.
C. Therapist as Competition: Defensive Masculinity in the Transference
In some cases, the patient may enter into a competitive and/or performative dynamic with the therapist. He unconsciously performs his masculinity, often trying to, and sometimes succeeding, in entering into power struggles with the therapist. He may frequently challenge the therapist’s competence and devalue them in an attempt to feel powerful, in control, and independent in light of his earlier experiences of powerlessness.
The therapist may respond by becoming defensive, competitive, or withdrawn. The therapist could feel attacked and defend their integrity and competence, leading the patient to either “come out on top” or be humiliated, ashamed, and mistrustful. Alternatively, they may fawn and become overly apologetic or shut down and withdraw.
D. Therapist as Sexual Object: Eroticized Shame and Seduction
Erotic transference and countertransference may also be present in the treatment relationship. The patient may rely on eroticism and seduction to protect himself from his own shame. He may try to flirt with the therapist through eye contact that feels sexual and excessive, frequent teasing, frequent compliments about the therapist’s appearance, and/or excessive questions about the therapist’s romantic and social life. He may only disclose fragments of his abuse in a conscious or unconscious attempt to “tantalize” the therapist. He may also have fantasies that he is uniquely special to the therapist or that the therapist is attracted to him. These dynamics are an attempt to prove his desirability in one of the few ways he may know how to and to restore agency through sexual expression.
The therapist may feel intruded upon, unsettled, reciprocally desirous, or more flexible than usual with boundaries. They may feel as though they have been violated or liable to potential violation. In response, the therapist might become highly rigid and distant with the patient in order to maintain clear boundaries. In some cases, the therapist may terminate treatment prematurely. Alternatively, the therapist may experience erotic countertransference, even if the patient is not someone they would usually be drawn to outside of the clinical encounter. They may have erotic dreams and fantasies about the patient. If erotic countertransference is not present, they may still experience enjoyment from the seduction and be more likely to soften boundaries as a result.
E. Working Through: From Enactment to Integration
As the relational dynamics that symbolize the abuse play out in treatment, it is important for the therapist to notice when they feel pulled into enactment. When the therapist withdraws, they unconsciously communicate to the patient that they do not care about him. When the therapist tries to relentlessly rescue him, they reinforce his self-perception of not having agency or being capable himself. When they enter into power struggles and competition, the patient is left feeling either a victim or perpetrator. When the therapist reacts to his eroticism with disgust, withdrawal, or overt reciprocal desire, he is left feeling that his body and his sexuality is to be ashamed of, or that he is nothing more than an object of sexual desire.
The therapist must remain compassionate with themselves and recognize that they will almost certainly engage in these dynamics. Healing for the male survivor requires relational stability, so the therapist should try as much as they can to not get pulled in too far. This starts with recognizing the impulse to do so and the ways in which they already have. If they are pulled in, they should make an effort to acknowledge, explore, and process those moments with the patient. This can be an incredibly illuminating and useful process for both the therapist and the patient. The patient has likely never had the experience of their abuser acknowledging any harm caused, so when the therapist is able to do so (even if that means just naming it), it can be profoundly impactful. Integration involves acknowledging and grieving the realities of the abuse itself as well as working through the relational dynamics that represent the abuse within the therapeutic relationship.
Groupwork as Reparative
Groupwork can be a powerful source of healing for the male survivor. He has likely carried a deep sense of loneliness, shame, and isolation. Even if he has disclosed his abuse to his individual therapist, he may continue to feel misunderstood, to the point of not feeling anyone can truly understand him. His relationship to masculinity and other men may continue to consist of distrust and fear.
The first relief that a male survivor often gets through groupwork is a lessening of isolation. The survivor witnesses other men speak openly and vulnerably about shame, confusion, rage, grief, and longing. His exposure to other men’s emotional expression within this contained environment allows him to gradually internalize a different version of maleness and masculinity.
Groupwork also offers collective regulation. Some members may struggle to speak openly about their abuse, while others may do so with little affect. The group can function as a regulatory system, where if one member feels overwhelmed, others might become attuned and grounded. On the other hand, if one member speaks without affect, others may express their sadness or anger over what’s being shared. This experience of being seen without humiliation or exploitation can be profoundly healing.
Shame, the key organizing affect of the male survivor, can lose some of its power and influence through group work. His secrecy and isolation become replaced by belonging, connection, and solidarity. He develops an ability to speak more openly about his abuse and how it has shaped him internally and interpersonally. Most importantly, he begins to recognize and believe that he is not defective or broken.
Clinical Imperatives
A. Pacing the Treatment
It is essential to try as best as possible to keep the pace of treatment within the patient’s window of tolerance. Discussion of the abuse can be highly dysregulating and the therapist must honor the patient’s nervous system (Herman, 1992). There should be no urgency to fully unpack all of the abuse, and it is important to communicate that explicitly to the patient. I often say, “We want to stay within your window of tolerance so you can go out and function in the world after your sessions. If this starts to feel too intense, we can always slow down. Just let me know.”
Attending to the patient’s here-and-now experience can also be very useful in pacing. With a more dissociated patient, I might ask, “What are you feeling in this moment?” in order to bring him closer to his emotional experience. On the other hand, with someone more prone to dysregulation (or a more dissociated patient who suddenly appears overwhelmed by a flood of emotions), I might instead ask, “How is it to talk about this right now?” and “What do you think you need in this moment?” and “Where are you between 1 and 10 right now in terms of your window of tolerance?” The goal is not catharsis, it is a slow and gradual process of integration.
B. Working With Erotic Transference
Erotic transference and countertransference are often the most challenging dynamics for the therapist to navigate because of their taboo nature, their ability to amplify shame, and their ability to affect both the therapist and the patient’s safety if acted out. The therapist must set clear and firm boundaries in a way that tries not to overly wound the patient. For a patient who discloses erotic feelings, a response can look something like, “I really appreciate you sharing that with me. I’m sure it wasn’t easy for you. It’s not uncommon for feelings like this to come up in therapy since this is a place where vulnerability and intimacy are present. At the same time, the therapy relationship has clear boundaries, and sexual intimacy is one of those boundaries.” After expressing the boundary, the therapist might have an impulse to try to interpret, but it is important not to do so yet. They should first allow the patient to process and respond. The therapist can explore what it is like for the patient to hear what was shared and what it would have been like for the patient if the therapist had responded differently. While boundaries are essential, the therapist should also strive for relational flexibility in order to show the patient that a safe relationship can exist within a context of intimacy, vulnerability, and closeness. The aim is not to suppress erotic material. Therapists want to be able to explore the patient’s erotic feelings and fantasies and to understand what lies beneath them. It is often the case that shame is one of the key driving forces driving the erotic charge.
If erotic transference is expressed in a more aggressive or grandiose way, boundaries might need to be stated/restated more firmly. If the therapist’s safety is a concern, consultation and possible referral is necessary. Erotic countertransference should be processed in supervision rather than disclosed to the patient, as any sexual contact or seduction by the therapist is a reenactment of the abuse and is very harmful.
C. Gender, Sexuality, and Cultural Considerations
The therapist’s gender, sexuality, and racial/ethnic/cultural background can affect the transference and countertransference manifestations in meaningful ways. A male therapist might evoke competition, comparison, or associations to a male perpetrator, leading to mistrust, power struggles, erotic transference, or feeling used. A female therapist might be more positioned as a rescuer, an unprotective parent, or someone to perform masculinity to, or it may generate associations to a female perpetrator, leading similarly to mistrust, power struggles, erotic transference, or feeling used. Aspects of these dynamics are often influenced by the patient’s sexual orientation. Further, a survivor may experience shame resulting from internalized homophobia, confusion regarding their arousal during the abuse, or worry how the therapist might perceive his sexuality following disclosure.
It is important to consider the patient’s culture within the context of norms, especially ones that are gender-based. In some contexts, cultural norms around masculinity may change the ways that the patient relates to disclosure, vulnerability, and the meaning of his victimization. The therapist must be open to learning about and respectful of the patient’s cultural narratives surrounding strength, sexuality, and honor.
D. Hopeful Recovery
Healing for a male survivor of CSA involves developing a relationship to his male identity that is differentiated from the abuse. It involves a reduction of his shame and an improved relationship to the parts of himself that continue to carry it. His interpersonal relationships and his relationship to himself can become more organized around emotional expression, willingness to take relational risks, valuing various forms of intimacy, and self-worth and less organized around dominance and humiliation or fear of being dominated and humiliated. Recovery often happens slowly and gradually. I like to tell patients, “You’ve been living this way for many years, it’s only expected that this will take some time, patience, and investment for you to see the change you want.” Over time, the male survivor will develop an increased tolerance for vulnerability, greater bodily awareness and agency, fewer relational enactments, and a growing ability to develop and sustain secure and healthy relationships. When shame stops being the organizing force, he no longer has to defend against being witnessed.
References
1in6. (2017). Sexual abuse & assault of boys & men: Confidential support for men.https://1in6.org/
Davies, J.M., & Frawley-O’dea, M.G.. (1994). Treating the adult survivor of childhood sexual abuse: a psychoanalytic perspective. Basic Books.
Gartner, R. B. (2001). Betrayed as Boys. Guilford Press.
Herman, J. (1992). Trauma and Recovery. Basic Books.
Leach, C., Stewart, A., & Smallbone, S. (2016). Testing the sexually abused-sexual abuser hypothesis: A prospective longitudinal birth cohort study. Child Abuse & Neglect, 51, 144–153. https://doi.org/10.1016/j.chiabu.2015.10.024
McLean, I. A., Balding, V., & White, C. (2004). Forensic Medical Aspects of Male-on-Male Rape and Sexual Assault in Greater Manchester. Medicine, Science and the Law, 44(2), 165–169. https://doi.org/10.1258/rsmmsl.44.2.165
Nathanson, D. L. (1992). Shame and Pride: Affect, Sex, and the Birth of the Self. Norton.